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- ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> ' PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW R NAME <br /> d 4k0�'o___'F- c---7:- <br /> ' C/P c v-1 P• t r ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 6/93 /4 9Aues-r- /),`I/ C-1 lua (,t.rq)c e (ALT- 53. 5 J Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> iJ all, C 1 P tni,P,?s, ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> e. is 3 /114,4 tile Nr?t/ <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> (,a 8 ‘3. 9� 2 r fc applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us!) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER o �f,g - 1 '43- gabs ? 3 , 6-5, frontage drawn to scale. <br /> TOWNSHIP: E TION: <br /> 1/4: 5-l.�. 141/4: s(ice LI Driveway permits <br /> ADDRESS: `� (state,county,town) <br /> 17 1St [atm.r -131-.'r4 v./ ante LI Sanitary permits <br /> CSM: /LOT / <br /> SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: !, n 1 <br /> '/ 11'Y! (N c(4 e' Ad�s s �� J 'mil Q ❑ Zoning District <br /> a•This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> ' / i. I ❑ Wetlandtf codplaint <br /> AREA TO NEAREST SQUARE FOOT: Shoreland {attanhmenf} <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: <br /> ❑ E ro s ton antral°pl permit <br /> TOTAL SQUARE FOOTAGE: 4 (slopes,?es,distur , <br /> `L <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: �./ g <br /> l� ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ 3 and available options. <br /> (Please round to nearest dollar) $ 1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> (C <br /> APPLICATION ontinue on Back)MU BE SIGNED <br /> ST <br /> 545-112(4/08) <br />